While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

The client's comfort level is increased when the nurse breaks eye contact to type notes into the record.

Completing the electronic record during an interview is a legal obligation of the examining nurse.

The nurse has limited ability to observe nonverbal communication while entering the assessment electronically.

The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is an incorrect statement as it implies that breaking eye contact is beneficial for the client. In fact, breaking eye contact may reduce the client's trust and rapport with the nurse. The nurse should maintain eye contact as much as possible and use verbal and nonverbal cues to show active listening.

Choice B reason: This is an incorrect statement as it implies that electronic documentation is mandatory for all interviews. In fact, electronic documentation is not a legal obligation, but a preferred method of recording the assessment data. The nurse should follow the facility's policy and procedure for electronic documentation and ensure the accuracy, completeness, and confidentiality of the record.

Choice C reason: This is the correct statement as it acknowledges the challenge of electronic documentation during an interview. The nurse may miss some important nonverbal cues from the client, such as facial expressions, gestures, or posture, while typing on the computer. The nurse should balance the time spent on the computer and the time spent on the client and use open-ended questions and reflective statements to elicit more information.

Choice D reason: This is an incorrect statement as it implies that electronic documentation is beneficial for the interview process. In fact, electronic documentation may interfere with the flow and quality of the interview. The client may feel rushed or ignored by the nurse's attention to the computer. The nurse should pace the interview according to the client's needs and preferences and use electronic documentation as a tool, not a barrier.

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Correct Answer is B

Explanation

Choice A reason: Eschar and slough in the wound are not signs of proper healing. They are necrotic tissue that impairs wound healing and increases the risk of infection. They should be removed by debridement to promote wound closure.

Choice B reason: A well-approximated incision site is a sign of proper healing. It means that the edges of the wound are close together and aligned, without gaps or separation. It indicates that the wound is healing by primary intention, which is the fastest and most desirable method of wound healing.

Choice C reason: Beefy red granulation tissue is a sign of healing, but not of proper healing for a surgical incision. It is new tissue that fills the wound bed and consists of blood vessels and connective tissue. It indicates that the wound is healing by secondary intention, which is a slower and less desirable method of wound healing.

Choice D reason: Erythema and serosanguineous exudate are not signs of proper healing. They are signs of inflammation and possible infection. Erythema is redness of the skin around the wound, and serosanguineous exudate is a mixture of blood and serum that drains from the wound. They should be monitored and reported to the health care provider.

A. "The healthcare provider will share this information with you." B. "I can give you those results as soon as I get them back from the lab." C. "I'm sorry, but your child's medical information is none of your business." D. "I can only give medical information to your child because they are legally an adult."

Correct Answer is D

Explanation

Choice A reason: This is an incorrect response as it implies that the healthcare provider will disclose the client's laboratory results to the parents. However, the client is emancipated and has the right to privacy and confidentiality of their medical information. The nurse should respect the client's autonomy and consent.

Choice B reason: This is an incorrect response as it implies that the nurse will share the client's laboratory results with the parents. However, the client is emancipated and has the right to privacy and confidentiality of their medical information. The nurse should respect the client's autonomy and consent.

Choice C reason: This is an incorrect and rude response as it insults the parents and disregards their concern. The nurse should be polite and professional when communicating with the parents. The nurse should explain the legal and ethical reasons for not disclosing the client's medical information.

Choice D reason: This is the correct and respectful response as it informs the parents that the client is emancipated and has the right to privacy and confidentiality of their medical information. The nurse should respect the client's autonomy and consent and only give medical information to the client or their designated representative.

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While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

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